What Causes Fear of Childbirth and How Can Midwives Support Women?

Introduction

The latest figures from the Vital Statistics Yearly Summary 2016, report that 63,897 babies were born in Ireland (Central Statistics Office, 2016). Those women experienced their pregnancy within the context of the Irish maternity system that assures the safety of women and their babies (Larkin et al. 2017). This experience is very personal, individual and unique for each woman (Nordeng et al., 2012).  Seminal work by Ann Oakley (1986) suggests that it is the moment that a woman becomes a mother that she faces the reality of what it means to be a woman in society. For many women, this experience is a defining moment in their life, however there are some women for whom the experience of childbirth creates an intense level of fear (Rouhe et al. 2008). The fear may overshadow the entire pregnancy, complicate labour, lead to difficulties in the mother–infant relationship, and to postpartum depression (Otley 2011). Although labour is a physiological process, there is a focus on the directly observable aspects of care such as quality of care, interventions, and mortality and morbidity measures (Larkin 2009). Where as the less obvious elements may be more significant to the woman in question.

Fear in pregnancy may manifest in nightmares, anxiety and physical symptoms (Rouhe et al.2011; Rouhe et al. 2008). Fear of childbirth may lie behind a woman’s request for elective caesarean section (Dehghani
et al. 2014) and may lead to unnecessary caesarean section without medical indication if FOC is untreated (Wiklund 2008). A study conducted by Rouhe et al. (2009) explored how parity influences the level of fear in a woman’s pregnancy. A convenience sample of 1400 pregnant women attending outpatient maternity clinics of a university central hospital in Finland completed a questionnaire to identify fear of childbirth with reference to parity, gestational age, and obstetric history. Results suggested that nulliparous women fear the unknown such as pain and loss of control whilst multiparous women fear arises from previous negative birth experiences. These findings are supported by the results from other researchers (Pazzagli et al. 2015; Toohill et al. 2014; Ternström et al. 2015; Adams et al. 2012; Fenwick et al. 2009; Hall et al. 2009; Lukasse et al. 2014; Haines et al. 2011).

Satisfaction is a common outcome used to describe the childbirth experience, however, the complexity of measuring such a multidimensional concept and methodological limitations are debated among many authors (van Teijlingen et al., 2003; Turris, 2005; Walsh, 2007). Complex issues may also be raised when asking women about their childbirth experiences such as the timing of the research and the relationship with the researcher (Larkin et al., 2009). By conducting a comprehensive literature review, Larkin et al. (2009) analysed the experience of childbirth and identified the core concept as a psychological and physiological life event, which is influenced by environmental, social, organisational and policy contexts. In Ireland, the emotional and psychological consequences of labour and birth have received little attention (Larkin et al. 2012). It is recognised internationally the relationship between the women’s psychological health and importance of identifying the woman’s needs around the time of birth and her childbirth experiences (Walsh 2007).

A qualitative descriptive study conducted by Larkin et al. (2012) consisted of focus group interviews that identified important aspects of women’s childbirth experiences. The aim of the study was to make women’s voices heard and to demonstrate that women’s feelings about their childbirth experiences were diverse but a powerful event resulting in strong emotions.

The findings of the study were limited the geographical location of four maternity units in the republic of Ireland and to a sample of women who were married and well educated, with little ethnic diversity. The results were that some women felt empowered by their experiences, others felt anxious, lonely and unsupported in labour. Similar results emerged from a qualitative study of 19 first-time mothers in Australia, which found that they benefited from preparation, communication and support (Dahlen et al., 2010).

Aim

The aim of this long assignment is to identify and critique the body of evidence that exists in relation to the topic on fear of childbirth. There will be a focus on the possible causes of FOC, which include biological, psychological, cultural and social factors. The experience of pregnancy and birth in relation to these factors will also be addressed. There will also be a focus on how midwives can support women by different approaches to care. A search of the databases reveals that the main body of work originates from Scandinavian countries. There will be a review of this literature whilst having an emphasis on the provision of care in the Irish context. This will be achieved by reviewing the current literature and national policies in place and the possible requirement of additional documents.

Due to the extent of literature on FOC, for the purpose of this literature review, there will be a focus on women only.

Rationale

The rationale of the long assignment is to develop a comprehensive understanding of FOC in order to inform my own midwifery practice. My desire is to obtain a comprehensive knowledge of FOC and develop the skill to support women experiencing this issue. I would like to make an impact on the women’s overall pregnancy experience by addressing her fears early on in the antenatal period. Acknowledging the fear and providing the appropriate care and education will hopefully have a positive impact on the pregnancy and future pregnancies. I would also like to create awareness in the hope that healthcare professionals will read my literature review and become inspired to make a difference.

After reading the ‘Midwife-Mother Relationship’ by Mavis Kirkham (2015), I was inspired by her passionate views on childbirth, which lead me to explore FOC. Emerging from her literature was the work of Grantly Dick-Read and his publication ‘childbirth without fear’ (1942). This book is an amazing piece of work where his philosophy is still as fresh and relevant as it was when he originally wrote it. He investigates the root causes of women’s fears and anxiety about pregnancy and childbirth with overwhelming passion and empathy.  One of my favourite quotes is ‘Good midwifery is essential for the true happiness of motherhood’. This quote underpins the importance of basic midwifery skills in improving the overall pregnancy experience for the woman. With my interest in motherhood and its influences, I read the book ‘Of Woman Born: Motherhood as Experience and Institution’ by Adrienne Rich (1995). This influential piece of work and investigates the experience of motherhood and how it is influenced by the institution. Rich’s work  is personal yet a relatable experience imposed on all women everywhere.

These three authors played an essential role in determining my topic for this literature review. My strong belief in the essence of midwifery care along with my sociological mind-set fuelled the passion behind this piece of work.

Search Strategy

Before the search strategy was conducted, key terms were constructed.

I began with a blank page where I brainstormed and wrote down ideas and main words relating to the topic.  Reading articles and getting ideas for other terms used also obtained keywords.  I then reviewed and examined studies addressing FOC and its definition, prevalence, causes and approaches to care.

These key terms were obtained through reading the literature, familiar terms from clinical practice and through the suggested database terms e.g. MeSH terms. Electronic databases Pubmed, Cinahl, PyscInfo, Embase, Midirs, the Cochrane Library, British Journal of Midwifery and AIMS Ireland were searched using the following search terms: ‘fear of childbirth’, ‘fear of birth’, ‘Childbirth’, ‘fear’, ‘anxiety’, ‘tokophobia*’, ‘Role of midwife’, ‘Causes’.

Upon my initial search, most articles were located in Scandinavian countries such as Sweden, Denmark and Norway. The searches lead to 180 articles, before reading the articles, assessment of title and abstract was performed. 65 were relevant by title, 15 were not relevant by title. Of the 65 articles remaining, 50 were relevant by the abstract. Limitations included humans, English language. A time limit to 10 years was applied after reading the article titles in order to avoid missing seminal pieces. The CASP tool was utilised to assist with focusing on critically appraising the articles. The search Strategy for PubMed, CINAHL, The Cochrane Library and PYSCINFO is included as Table 1 in Appendix.

Prevalence

The prevalence of fear of childbirth varies among different countries. Reported in the literature includes the FOC rate of 7.5%-8% in Norway (Nordeng et al., 2012; Adams et al., 2012; Storksen et al., 2012) 9.2% in Canada (Spice et al., 2009) and between 10.0% and 15.8% in Sweden (Kjaergaard et al., 2008; Nieminen et al., 2009). The prevalence rate varies considerably among countries due to the timing of assessment, type of assessment tool used and the cultural context (Waldenstrom et al. 2006).

Many authors have explored the factors associated with increased prevalence of fear of childbirth, including young maternal age, lack of social support, multiparous, pre-existing psychological problems, and a history of abuse or adverse obstetric events (Rouhe et al., 2009; Heimstad et al., 2006; Hofberg & Ward, 2003; Rouche et al., 2011). (will develop this)

The following section relates to complications/outcomes of FOC

Studies have found that fear of childbirth is associated with increased use of pharmacological pain relief (Adams et al., 2012; Alipour et al., 2011), longer delays in delivery (Adams et al., 2012; need to add more studies), higher rates of instrumental and operative vaginal deliveries (Adams et al.,2012; Heimstad et al., 2006), emergency caesarean section (Nilsson et al. 2011; Ryding et al., 2007), request for elective caesarean section (Nieminen et al., 2009; Waldenstrom, 2006) and self-reported negative birth experience (Nilsson et al., 2011; Ryding et al., 2007). As well as physical impact, it may have a physiological impact also. A previous study shown that emergency caesarean section, vacuum delivery, and untreated or unbearable pain during labour can lead to post-traumatic stress disorder (PTSD) and to fear of childbirth in subsequent pregnancies (Soderquist et al. 2006).

Why this is an issue

An intense fear of childbirth is a serious issue for many women that can greatly impact their physical and psychological wellbeing. A woman’s experience of birth can have a significant impact on her wellbeing and that of her baby, partner, and family (Lundgren et al. 2009). In Ireland, there is a lack of research on women’s opinions regarding important components of their childbirth experiences (Larkin et al. 2017).  AIMS Ireland (2010) conducted a survey What Matters to You?: A Maternity Care Experience Survey of 367 women. One of the areas explored were women’s experiences of labour and birth. The survey yielded varied results yet the overall areas of concern were informed consent and respect from health care workers. By having this respect and continuity of care will reduce the woman’s fear of childbirth (Christiaens et al. 2011). The main message from the survey was the lack of choice in the Irish maternity system; this issue was assessed further in another survey in 2014 with 91.7% of respondents requesting the choice of a freestanding birth centre. The increasing emphasis on continuity and choice in maternity services has not evolved in the Republic of Ireland compared those developed in the UK and Northern Ireland (Kennedy 2010). However, Ireland’s recently published first National Maternity Strategy recommends that women be offered choice regarding their preferred pathway of care and that all care pathways should support the normalisation of pregnancy and birth (DOH 2016). Maternity services in Ireland are within a busy hospital environment and cannot always provide optimal supportive environments for women (Larkin 2012). A study by (Christiaens et al. 2011) based in the Netherlands and Belgium explored women’s fear of childbirth in midwifery led care versus obstetric led care. A total of 833 women completed an antenatal questionnaire at 30 weeks of pregnancy, resulting in both Belgian and Dutch women receiving midwifery care reported less fear compared to those in obstetric antenatal care.

Definition

Fear of childbirth has been defined in various ways such as self- reported fear (Nilsson et al. 2012), by screening with validated and non- validated questionnaires (Wijma et al. 1998, Saisto et al. 2006, Nieminen et al. 2009) and as a referral to a special maternity unit because of FOC (Saisto et al. 2006, Raisanen et al. 2014), which can cause inconsistency in definition and prevalence. To date, in the literature, there is still no consensus on the exact definition of fear of childbirth.  A French psychiatrist by the name Marché wrote the first literature on FOC in 1858, describing the fear as a ‘state of inexpressible anxiety’. Despite the lack of a clear definition in the literature, there is an agreement that women with FOC are concerned about the wellbeing of their baby and themselves (Wijma 2009). Fear of childbirth can also be referred to as tokophobia, which is defined as a severe fear of childbirth or an unreasoning dread of childbirth (O’Connell et al. 2017). (could go into the concept of unreasoning)  This definition is a relatively new concept first introduced by Hofberg and Brockington (2000), leading the term to become a medical condition. There has been conflicting evidence as to the prevalence of tokophobia in nulliparous and multiparous women (Lukasse 2014; Toohill et al. 2015). FOC is more common in nulliparous women (Melender 2002, Fenwick et al. 2009) who have fears about the unknown. In multiparous women FOC is often based on previous experiences (Ryding et al. 2007). Wijma et al. (1998) designed the first assessment instrument to measure specifically the intensity of FOC. Arising from this assessment tool was a variation in scores suggesting that the definition of FOC differs considerably among studies.

Causes of FOC

Emerging from the research are a number of causes of FOC, including fear of pain in labour and negative birth stories which is associated with shame, suffering, loss of control and helplessness (Fenwick et al., 2009).  According to Otley (2016) possible causes of FOC can be influenced by biological factors, psychological factors, social factors, cultural factors and previous negative experiences. Klabbers et al. (2016) further discuss how the aetiology of FOC is likely to be multifactorial and may be influenced by the person and situational factors. The multiple factors, including social support, a woman’s relationship with her care providers, cultural context, and personal characteristics, contribute to the general successes and difficulties she faces during the perinatal period (Kwee 2016). A negative birth experience increases the risk of negative health outcomes, such as postpartum depression (Bell & Andersson 2016) and future fear of giving birth (Nilsson et al. 2012), that can lead to a request for caesarean birth in future pregnancies (Pang et al. 2008), and have an impact on future reproduction (Larkin et al. 2012).

Social and cultural Factors

One of the reasons for the variation in the prevalence of FOC is the societal and cultural influence. Although birth is inherently psychosocial, a mother’s social and psychological needs can be often be neglected by health care workers focusing on the physical health of mother and baby (Brown et al., 2009; McConachie &  Whitford, 2009). For some women, pregnancy and childbirth is the beginning of cultural and societal changes. The concept of the woman becoming a mother is highly respected in some societies (Oakley 1986). Women continue to be defined as mothers and birth continues to be heavily medicalised, with increasing use of technology in western cultures (Oakley 2005). In today’s modern society, pregnant women are identified as patients who become easily influenced and compliant to the power of medical professionals (Murphy-Lawless 2011a). Rich (1995) describes how the medicalisation of childbirth determines the woman’s birth experience due to patriarchal powers. This institutional approach to care leads to ‘alienation’ of the woman from her birthing process (Rich 1995). This medically imbued cultural representation of birth devalues women’s labour in childbirth (Oakley 2005), which suggests that women require professional male assistance (Oakley 2005). The medical model generally focuses on physical and reproductive success and is measured in terms of levels of perinatal mortality and morbidity (Oakley 2005) thus ignoring the emotional, psychological or social aspects of childbirth (Larkin et al. 2012). The emotional and psychological component of pregnancy must be acknowledged as they can have an impact on morbidity (Hunter et al. 2008, Edwards 2005).

Pregnancy and childbirth can be shaped by the cultural and societal attitudes towards motherhood. Once a woman becomes a natural mother, she develops into a person with no other identity (Oakley 1986; Rich 1995; Murphy Lawless 2011a). However, Edwards (2005) disagrees and believes that once a woman gives birth to her baby, she may be its mother but her role as a mother in the social sense commences when she begins to care for her child. Her role as a mother can be shaped by the idealistic depiction of motherhood in the media. Pregnancy and birth are portrayed ad potentially problematic and associated with disease, requiring management in hospital institutions (Coxon et al., 2012). Although pregnancy is considered to be normal and healthy, this is only in retrospect (Oakley 2005). The media are quick to point the finger and blame, distorting the notion that childbirth is not a natural life event but an event that requires detailed intervention and surveillance (Coxon et al., 2012).

Despite the depiction of childbirth in the media, Healey et al. (2016) believe that advancements in maternity care have resulted in a continuing decline of maternal and infant mortality rates within developed countries. This statement is confirmed by Infant perinatal mortality rates currently standing at 5.9/1000 births in Ireland, representing a decrease of 31% since 2003 (Economic and Social Research Institute (ESRI), 2013).  Knight et al. (2016) examined direct maternal mortality rates in the UK and Ireland being as low as 2.86/100000 women. Although these figures are reassuring for both women and health professionals, Healy et al. (2016) believe that current practices do not reflect this leading to an increased fear of childbirth.

A metasynthesis study by Nelson (2003) reveals that despite commonalities in in the perception of motherhood, all mothers do not experience becoming a mother in the same way. This creates a challenge for health care workers for to identify the needs of each mother and to offer individualised support (Nelson 2003). (will discuss working conditions and barriers to help FOC.)

When ‘safety’ relates to physical elements only, other aspects of experiences such as psychological safety may be underestimated (Walsh, 2007).

The context within which women give birth in the Republic of Ireland is important to their birth experiences (Larkin et al. 2012).

Biological Factors

Currently working on this section to include interventions and c section

Birth has the potential to be a transforming event in a woman’s life. Some women may experience empowerment in their pregnancy yet the personal confidence in their capacity to give birth has declined leading to increased levels of FOC  (Edwards & Murphy-Lawless 2006). The unique and universal event of giving birth can be experienced as a growth enhancing and positive or a negative traumatising (Kwee 2016). Women report their experiences with either positive or negative outcomes to be pivotal in shaping their identities as a mother (Dahlen et al., 2010).

Psychological factors

Many authors have demonstrated a connection between fear of childbirth and psychiatric illness which include depression, anxiety, eating and bipolar disorders (Andersson et al., 2003;  Andersson et al., 2004; Ryding et al., 2007). Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women experiencing depression and 13% experiencing anxiety at some point, many women will experience both (NICE 2014).  Perinatal Mental Health is a term used when describing mental health difficulties for women emerging from conception to one year following birth (Austin et al. 2013). These disorders can have a significant impact on maternal and infant health (Alderdice et al. 2012; Jones et al. 2012; Rollans et al. 2012) including obstetric complications during childbirth and pregnancy (Hauck et al. 2013). Perintal mental health is a significant public health issue yet the detection of mental health difficulties may be overlooked in maternity services (Rothera & Oates 2008, Austin et al. 2013, Glover 2014). Indicators of depression and anxiety may be missed in general routine antenatal care (Alder et al. 2011). Currently in Ireland, there is no data collected to demonstrate routine mental health screening or monitoring of perinatal mental health complications. However, with the recent publication of the National Maternity Strategy (DOH 2016), this screening may take place at local level and in individual units.

By failing to screen for mental health issues, poor maternal mental health has shown to negatively impact mothers’ physical health, mother–infant bonding, the mother’s role as a parent, and physical, emotional, behavioral, and cognitive development of the child (Chuang et al., 2011; Hart & McMahon, 2006; Sabuncuoglu & Basgul, 2016; Topiwala et al., 2012). Pre-term birth is a predictor of greater rates of maternal depression and anxiety when a woman is experiencing FOC and a mental health condition (Bouras et al., 2015).  A meta-synthesis of the results of nine qualitative studies by Nelson (2003) related to the transition to motherhood, indicates that despite antenatal preparation, new mothers can feel overwhelmed and unprepared in becoming a mother.

Providing psychological and mental health support to mothers, children and families in the perinatal period is considered an important global (WHO 2013) and national health issue (Department of Health and Children 2006; Department of Health 2016), as early recognition and intervention can improve maternal and infant outcomes. Midwives as part of the multidisciplinary healthcare team, are in an optimal position to address mental health and emotional wellbeing with women in the perinatal period (Higgins et al. 2017). However, research involving midwives in Ireland indicates considerable variation in perinatal mental health assessment and care, with lack of skill in opening a discussion, lack of education, lack of organisational issues, such as lack of policies, guidelines and care pathways, as barriers to addressing perinatal mental health issues (Higgins et al. 2017; Brady et al. 2017).

A vast majority of research have concentrated on symptoms of anxiety and depression during pregnancy (Andersson et al., 2003; Andersson et al., 2004; Ryding et al., 2007; Huizink et al., 2004), yet they have excluded women with diagnosed mental illnesses due to the lacking of large population size (Rouhe et al. 2011). A study conducted by Rouhe et al. (2011) investigated the relationship between FOC and psychiatric co-morbidity. The aim of this register-based study (will find an accurate definition) was to examine if the women who fear vaginal childbirth have mental health problems more often than same aged parous Finnish women in general. The outcome was that mental health problems were twice as common among women with a fear of childbirth compared to women experiencing no fear. (will include more details about the study such as measurement and variables).

Saisto & Halmesmaki (2003) (will update reference) reported anxiety as the most important factor predicting fear of vaginal childbirth. However this study was based on self-reported questionnaires and conducted only during pregnancy and not postnatally (will explain this).  Recent cohort studies have reported prevalence rates of anxiety and depression during pregnancy similar to those in the postpartum period (Alder et al., 2007; Andersson et al., 2006; Levine et al., 2003) (will update reference). More specifically, clinically relevant levels of anxiety and stress are reported in 7% to 21% of pregnant women (Borri et al., 2008; Grant et al., 2008).

Implications for practice/approaches to care

Antenatal education

Antenatal education programmes in hospital-based settings are currently endorsed by the Irish State (Government of Ireland, 2004). Evidence suggests that the facilitation of antenatal classes are a vital component of the maternity services and advertised free of charge for all women (Cuidiú, 2015).  There is tension around the quality of antenatal education and the difference between supporting women in preparation of birth and the institutional powers of place of birth (Kitzinger, 2005; Brixval et al., 2015).  Many view hospital-based education as medicalised and compliant to the medical model (Kennedy 2002; Kitzinger 2005; AIMSI 2010), however the role of the education is to empower women and acknowledge their individual needs (Kitzinger 2006; Nolan 2010). A study by Brady & Lalor (2017) presented women’s needs in preparation for birth and motherhood by using participatory action research. The findings from the research suggest that women lack confidence in their power to birth, which lends the power to hospital policy and personnel to determine the birthing outcome. The study recommends that antenatal education should offer an informal forum to facilitate interactive dialogue with healthcare professionals but also with other mothers to share their birthing experiences. Women’s desires to hear birthing stories from other women are reoccurring themes from the research and supported by many authors (Nolan et al. 2012; Leap et al. 2010; Kitzinger 2006). Research by Karlstrom et al. (2015) and Schwartz et al. (2015) suggest that confidence and self-trust in ability to birth is an important indicator of the woman’s fear and coping abilities. Fear of birth along with fear of loneliness and isolation can be aided with the real life experiences of other mothers and with the empowering and supportive antenatal education (McLeish & Redshaw 2015; Nolan et al. 2012).

Risk

Originally, risk management was designed to protect, but in today’s modern healthcare, risk management may be exposing women to more intervention that is necessary (Edwards and Murphy-Lawless, 2006). Consequently, the language of pregnancy and birth has evolved to incorporate words such as ‘hazard’, ‘harm’, ‘blame’, ‘vulnerability’ and ‘safety’ (MacKenzie Bryers & van Teijlingen, 2010). Scamell & Alaszewski (2012) agree and believe this language was developed from heightened and often irrational perceptions of risk.

Scamell (2014) believes that many women have become hypersensitive in their views towards birth and suggests that this is based on a fear of possible risk, rather than from any substantial experience. Rothman (2014) disagrees and explains for risk to have a benefit it must be intelligently balanced, contextualised and weighed. It is contended by Edwards & Murphy-Lawless (2006) that the media contribute to the augmentation of risk by reporting on it emotionally as opposed to intellectually, resulting in the severity of outcomes outweighing the probability of them in women’s perceptions. The media are quick to point the finger and blame, distorting the notion that childbirth is not a natural life event but an event that requires detailed intervention and surveillance (Coxon et al., 2012).

The following section relates to the measurement of FOC

Wijma et al. (1998) designed the first assessment instrument to measure specifically the intensity of FOC rather than general anxiety. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) consists of 33 item rating scale with a response format ranging from ‘not at all’ (0) to ‘extremely’ (5), leading to a score range between 0 and 165. According to Wijma et al. (1998) a score of >85 is considered to indicate FOC. Despite the questionnaire being utilised globally, different countries have various cut off scores when it applies to diagnosing women with FOC (Klabbers et al., 2016). For example a W-DEQ  score > 100 (Rouhe et al., 2012), W-DEQ  score > 85 (Kjærgaard et al., 2008; Klabbers et al., 2014) and W-DEQ  score > 66 (Toohill et al., 2014). The variation in scores suggests that the definition of FOC differs considerably among studies. – midwives can use this tool

A systematic review conducted by Nilver et al. (2017) aimed to identify and present validated instruments measuring women’s childbirth experience.  The search was narrowed down to 46 included papers representing 36 instruments. The systematic review did not narrow it down to a specific instrument to use but provides an overview of existing instruments measuring women’s childbirth experiences and can support researchers to identify appropriate instruments to be used.

Recommendations

Routine question at booking history and antenatal visits to discuss women’s feelings and fears around her pregnancy and birth. ‘How do feel about delivering your baby?( Study from Sweden). Aura teams used in hospitals.

Informed consent is recommended as women feel in control of their body and in turn trust the care they receive from the midwife. (Reference)

Increasing access to psychological services, by embedding them into routine maternity care, affords women opportunities for increased empowerment and thriving, while reducing risk factors for trauma, depression, anxiety, and poor maternal–infant attachment (Kwee 2016).

The importance of the identified attributes also requires organisational and policy development within the context of a cultural environment that acknowledges this diversity (larkin 2009).

Measuring the quality of maternity services must encompass recognition of psychological and emotional well-being alongside physical safety (Larkin et al 2012).

The recently published national maternity strategy states that ‘Women at risk of developing or experiencing emotional or mental health difficulties in the perinatal period should be identified, and a multi-disciplinary approach to assessment and support adopted’ (Department of Health 2016). In addition, the National Institute for Health Care Excellence (NICE 2014) recommends that a general discussion regarding mental health and well-being take place with all women at the first point of contact in pregnancy and in the early postnatal period, and that questions about mental health and emotional well-being are asked at each encounter.

Recommendations from the Royal College of Obstetricians and Gynaecologists (2011) state that every obstetric unit need a defined care pathway for referring women to local specialised perinatal mental health services, or general psychiatric services, if these are not available (RCOG 2011).

(Have removed the following references in text (Heimstad et al., 2006; Rouhe et al., 2009; Waldenstrom et al., 2006) Scamell and Alaszewski, 2015)

References

Adams S., Eberhard-Gran M. & Eskild A. (2012) Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. BJOG 119, 1238–1246.

Association for Improvement in the Maternity Services, Ireland AIMSI (2010) What Matters to You? A Maternity Care Experience Survey. AIMSI, Dublin

Alder J., Fink N., Bitzer J., Hosli I. & Holzgreve W. (2007) Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A

critical review of the literature. Journal of Maternal-Fetal & Neonatal Medicine 20, 189-209.

Alderdice F., McNeill J. & Lynn F. (2012) A systematic review of interventions to improve maternal mental health and well -being. Midwifery 29(4), 389 -399.

Alipour Z., Lamyian M. & Hajizadeh, E. (2011). Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women. Women and Birth : Journal of the Australian College of Midwives 25(3), 37-43.

Andersson L., Sundstrom-Poromaa I., Bixo M., Wulff M., Bondestam K. & Astrom M. (2003) Point prevalence of psychiatric disorders during the second trimester of pregnancy: a population-based study. Am J Obstet Gynecol 189, 148–154.

Andersson L., Sundstrom-Poromaa I., Wulff M., Astrom M. & Bixo M. (2004) Implications of antenatal depression and anxiety for obstetric out-come. Obstet Gynecol 104, 467–476.

Andersson L., Sundstrom-Poromaa I., Wulff M., Astrom M. & Bixo M. (2006). Depression and anxiety during pregnancy and six months postpartum: A follow-up study. Acta Obstetricia et Gynecologica Scandinavica 85, 937-944.

Austin M. P., Middleton P., Reilly N. & Highet N. J. (2013) Detection and management of mood disorders in the maternity setting: The Australian Clinical Practice Guidelines. Women and Birth 26, 2 -9

Bell A.F & Andersson E. (2016) The birth experience and women’s postnatal depression: A systematic review. Midwifery 39112–123.

Borri C., Mauri M., Oppo A., Banti S., Rambelli C., Ramacciotti D. & Cassano G. B. (2008) Axis I psychopathology and functional impairment at the third month of pregnancy: Results from the Perinatal Depression-Research and Screening Unit (PND-ReScU) study. Journal of Clinical Psychiatry 69, 1617-1624.

Bouras G., Theofanopoulou N., Mexi-Bourna P., et al. (2015) Preterm birth and maternal psycho- logical health. Journal of Health Psychology 20(11), 1388–1396.

Brady V. & Lalor J. (2017) Space for human connection in antenatal education: Uncovering women’s hopes using Participatory Action Research. Midwifery 55, 7–14.

Brady V., Madden D., Sliney A.M., O’Friel A., McMackin B., O’Callaghan B., Casey K. & Courtney L. (2017) Using action research to develop midwives’ skills to support women with perinatal mental health needs. (In press) (need to check this reference).

Brixval C.S., Axelsen S.F., Lauemøller S.G., Andersen S.K., Due P. & Koushede V. (2015) The effect of antenatal education in small classes on obstetric and psychosocial outcomes – a systematic review. Systematic Reviews 4.

Brown M., Mills N., McCalmont C., et al. (2009) Perinatal mental health services. Primary Health Care 19(8): 36–39.

Central Statistics Office (2016) Vital Statistics Yearly Summary

2016. http://www.cso.ie/en/releasesandpublications/ep/pvsys/vitalstatisticsyearlysummary2016/

Chuang C., Jeng S., Hsieh W., et al. (2011) Maternal psychosocial factors around delivery and the behavior of 2-year-old children. Pediatrics International 53, 656–661.

Coxon K., Scamell M. & Alaszewski A. (2012) Risk, pregnancy and childbirth: What do we currently know and what do we need to know? An editorial. Health, Risk & Society 14(6), 503–510

Cuidiú Irish Childbirth Trust (2015). Bump2Babe The Consumer Guide to the Maternity Services in Ireland. http://www.bump2babe.ie/. (Accessed 28 September 2017).

Dahlen H.G., Barclay L.M. & Homer C.S.E. (2010) The novice birthing: theorising first- time mothers’ experiences of birth at home and in hospital in Australia. Midwifery 26, 53–63.

Dahlen H.G., Barclay L.M. & Homer C.S. (2010) Processing the first birth: Journeying into “motherland.” Journal of Clinical Nursing 19(13–14), 1977–1985.

Dehghani M., Sharpe L. & Khatibi A. (2014)  Catastrophizing mediates the relationship between fear of pain and preference for elective caesarean section. European Journal of Pain 18, 582–589.

Department of Health and Children (DOH&C) (2006). A vision for change: Report of the expert group on mental health policy. Dublin: Stationery Office.

Department of Health (2016) Creating a better future together: National Maternity Strategy 2016-2026. Dublin: Department of Health. http://health.gov.ie/wp-content/ uploads/2016/01/Maternity-Strategy-web.pdf. Accessed 10^th September 2017.

Edwards NP. & Murphy-Lawless J. (2006) The instability of risk: women’s perspectives on risk and safety in birth. In: Symon A, ed. Risk and choice in maternity care: an international perspective. Churchill Livingstone, London: 35–50.

Economic and Social Research Institute (2013) Perinatal Statistics Report 2012. ESRI, Dublin.

Fenwick J., Gamble J., Nathan E., Bayes S. & Hauck Y. (2009) Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs 18(5), 667–677.

Glover V. (2014) Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Practice and Research Clinical Obstetrics and Gynaecology 28, 25 -35.

Government of Ireland (2004). Maternity Protection (Amendment) Act. Irish Statute Book Office of the Attorney General. http://www.irishstatutebook.ie/eli/2004/act/28/section/8/enacted/en/html#sec8. (Accessed 28 September 2017).

Grant K. A., McMahon C. & Austin M. P. (2008) Maternal anxiety during the transition to parenthood: A prospective study. Journal of Affective Disorders 108101-111.

Griffiths P. & Barker-Collo S. (2008) Study of a group treatment program for postnatal adjustment difficulties. Archives of Women’s Mental Health11, 33–41.

Haines H., Pallant J.F, Karlstrom A. & Hildingsson I. (2011) Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery 27(4), 560-7.

Hall W.A., Hauck Y.L., Hutton E.K., Fenwick J. & Stoll K. (2009) Childbirth Fear, Anxiety, Fatigue, and Sleep Deprivation in Pregnant Women. Journal of Obstetric and Gynecology and Neonatal Nursing 38(5), 567-576.

Hart R. & McMahon C.A. (2006) Mood state and psychological adjustment to pregnancy. Archives of Women’s Mental Health 9, 329–337.

Hauck Y., Allen S., Ronchi F., Faulkner D., Frayne J., & Nguyen T. (2013) Pregnancy Experiences of Western Australian Women Attending a Specialist Childbirth and Mental Health Antenatal Clinic. Healthcare for Women International 34, 380 – 394.

Healy S., Humphreys E. & Kennedy C. (2016) Can maternity care move beyond risk? Implications for midwifery as a profession.  British Journal of Midwifery 24 (3), 203-209.

Heimstad R., Dahloe R., Laache I., Skogvoll E. & Schei B (2006) Fear of child- birth and history of abuse: implications for pregnancy and delivery. Acta Obstet Gynecol Scand 85 (4), 435–440.

Higgins A., Carroll M., Gill A., Downes C. & Monahan M. (2017) Perinatal Mental Health Care: Best Practice Principles for Midwives, Public Health Nurses and Practice Nurses. Dublin: Health Service Executive.

Hofberg, K., & Brockington, I. (2000). Tokophobia: An unreasoning dread of childbirth. British Journal of Psychiatry, 176, 83-85.

Hofberg K. & Ward MR. (2003) Fear of pregnancy and childbirth. Postgrad Med J 79, 505–510.

Huizink AC., Mulder EJ., Robles de Medina PG., Visser GH. & Buitelaar JK. (2004) Is pregnancy anxiety a distinctive syndrome? Early Hum Dev 79, 81–91.

Jones C. J., Creedy D. K., Gamble J. A. & Health M. (2012) Australian midwives’ attitudes towards care for women with emotional distress. Midwifery 28, 216 -221.

Karlström A., Nystedt A. & Hildingsson I. (2015) The meaning of a very positive birth experience: focus groups discussions with women. BMC Pregnancy and Childbirth 15, 251.

Kennedy P. (2010) Healthcare reform: Maternity service provision in Ireland. Health Policy. 97(2), 145–151.

Kitzinger S. (2005) The Politics of Birth. Elsevier Butterworth-Heinemann, Edinburgh.

Kitzinger S (2006) Birth Crisis. New York: Routledge.

Klabbers, G.A., Wijma, K., Paarlberg, K.M., Emons, W.H.M., & Vingerhoets, A.J.J.M. (2014). Treatment of severe fear of childbirth with haptotherapy, a multicentre randomized controlled trial. BMC, Complementary and Alternative Medicine, 14, 385.

Kjærgaard, H., Wijma, K., Dykes, A-K., & Alehagen, S. (2008). Fear of childbirth in obstetrically low-risk nulliparous in Sweden and Denmark. Journal of Reproductive and Infant Psychology, 26, 340-350.

Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P. & Kurinczuk JJ eds. (2016) Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. MBRRACE-UK/ National Perinatal Epidemiology Unit, Oxford

Kwee J. (2016) Working together for women’s empowerment: Strategies for interdisciplinary collaboration in perinatal care. Journal of Health Psychology: An Interdisciplinary, International Journal 21(11), 2742-2752.

Larkin P., Begley C. & Devane D. (2009) Women’s experiences of labour and birth: an evolutionary concept analysis. Midwifery 25, 49–59.

Larkin P., Begley C. & Devane D. (2017) Women’s preferences for childbirth experiences in the Republic of Ireland; a mixed methods study. BMC Pregnancy and Childbirth 17(19), 1-10.

Larkin P., Begley C.M. & Devane D. (2012) “Not enough people to look after you”: An exploration of women’s experiences of childbirth in the Republic of Ireland. Midwifery 28, 98–105.

Laursen M,. Johansen C. & Hedegaard M. (2009) Fear of childbirth and risk for birth complications in nulliparous women in the Danish National Birth Cohort. BJOG 116:1350–1355.

Leap N., Sandall J., Buckland S. & Huber U. (2010) Journey to confidence: women’s experiences of pain in labour and relational continuity of care. Journal of Midwifery and Women’s Health 55, 234–242.

Levine R. E., Oandasan A. P., Primeau L. A. & Berenson A. B (2003). Anxiety disorders during pregnancy and postpartum. American Journal of Perinatology 20, 239-248.

Lukasse M., Schei B. & Ryding E.L. (2014) Prevalence and associated factors of fear of childbirth in six European countries. Sexual and Reproductive Health 5(3), 99-106.

Lundgren I., Karlsdottir S.I. & Bondas T. (2009) Long-term memories and experiences of childbirth in a Nordic context a secondary analysis. Int J Qual Stud Health Well-being 4, 115–128.

MacKenzie Bryers H. van Teijlingen E. (2010) Risk, theory, social and medical models: a critical analysis of the concept of risk in maternity care. Midwifery 26(5), 488–496.

McConachie S. & Whitford H. (2009) Mental health nurses’ attitudes towards severe perinatal mental illness. Journal of Advanced Nursing 65(4), 867–875.

McGrath P. & Ray-Barruel G. (2009). The easy option? Australian findings on mothers’ perception of elective Caesarean as a birth choice after a prior Caesarean section. International Journal of Nursing Practice 15, 271–279.

McLeish J. & Redshaw M. (2015) Peer support during pregnancy and early parenthood: a qualitative study of models and perceptions. BMC Pregnancy and Childbirth 15, 257.

Melender H.L. (2002) Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women. Birth 29, 101-111.

Murphy-Lawless J. (2011a) Childbirth Adrift in Ireland. Association fo r Improvements in the Maternity Services. AIMS Journal 23(3).

Nieminen K., Stephansson O. & Ryding E. L. (2009) Women’s fear of childbirth and preference for cesarean section–a cross-sectional study at various stages of pregnancy in sweden. Acta Obstetricia Et Gynecologica Scandinavica  88(7), 807-813.

NICE (2014) Antenatal and postnatal mental health: clinical management and service guidance…

Nilvér H., Begley C. & Berg M. (2017) Measuring women’s childbirth experiences: a systematic review for identification and analysis of validated instruments. BMC Pregnancy and Childbirth 17, 203.

Nolan M. (2010) Childbirth education: politics, equality and relevance. In: Walsh D. & Downe S. (Eds.), Essential Midwifery Practice: Intrapartum Care. Wiley-Blackwell, Sussex.

Nolan M., Mason V., Snow S., Messenger W., Catling J. & Upton P. (2012) Making Friends at Antenatal Classes: a Qualitative Exploration of Friendship Across the Transition to Motherhood. The Journal of Perinatal Education 21, 178–185.

Nordeng, H., Hansen, C., Garthus-Niegel, S., & Eberhard-Gran, M. (2012). Fear of childbirth, mental health, and medication use during pregnancy. Archives of Women’s Mental Health, 15, 203-209.

Nilsson C., Lundgren I., Karlstrom A. & Hildingsson, I. (2012). Self reported fear of childbirth and its association with women’s birth experience and mode of delivery: A longitudinal population-based study. Women and Birth : Journal of the Australian College of Midwives 25(3), 114-121.

Oakley A. (1986) From Here to Maternity. Becoming a Mother Penguin Books Ltd., Harmondsworth.

Oakley A. (2005) The Ann Oakley Reader. Gender, Women and Social Science. The Policy Press, Bristol.

O’Connell, M., Leahy-Warren, P., Khashan, A., Kenny, L. & O’Neill, S. (2017) Worldwide prevalence of tocophobia in pregnant women: systematic review and meta-analysis, Acta Obstetricia Et Gynecologica Scandinavica, 96(8), 907-920.

Otley, H. (2011) Fear of childbirth: Understanding the causes, impact and treatment.

British Journal of Midwifery 19 (4), 215-220.

Pang M.W, Leung T.N, Lau T.K & Hang Chung T.K. (2008) Impact of first childbirth on changes in women’s preference for mode of delivery: follow-up of a longitudinal observational study. Birth 35(2), 121–128.

Pazzagli C., Laghezza L., Capurso M., Sommella C., Lelli F. & Mazzeschi C. (2015) Antecedents and consequences of fear of childbirth in nulliparous and parous women. Infant Mental Health Journal 36(1), 62-74.

Raisanen S., Lehto S.M., Nielsen H.S., Gissler M., Kramer M.R., Heinonen S. (2014) Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in Finland in 1997-2010. BJOG 121, 965-970.

Rich A. (1995) Of Woman Born. Motherhood as Experience and Institution. Virago, London.

Rollans M., Schmied V., Kemp L. & Meade T. (2013) Digging over that old ground: an Australian perspective of women’s experience of psychosocial assessment and depression screening in pregnancy and following birth. BioMed Central Women’s Health 12, 18.

Rothera I. & Oates M. (2008) Managing perinatal mental health disorders effectively: identifying the necessary components of service provision. The Psychiatrist 32, 131 – 133.

Rothman B.K. (2014) Pregnancy, birth and risk: an introduction. Health, Risk & Society 16(1), 1–6.

Rouhe, H., Salmelo-Aro K, Tolvanen, R., Tokola, M., Halmesmäki, E., & Saisto, T. (2012). Obstetric outcome after intervention for severe fear of childbirth in nulliparous women – randomised trial. BJOG International Journal of Obstetrics and Gynaecology, 120, 75-84.

Rouhe H., Salmela-Aro K., Gissler M., Halmesmaki E. & Saisto T. (2011) Mental health problems common in women with fear of childbirth. BJOG 118, 1104–1111.

Rouhe H., Salmela-Aro K., Halmesmaki E. & Saisto T. (2009) Fear of childbirth according to parity, gestational age, and obstetric history. BJOG 116, 67–73.

Ryding E., Wirfelt E., Wangborg IB., Sjogren B. &Edman G. (2007) Personality and fear of childbirth. Acta Obstet Gynecol Scand 86, 814–820.

Sabuncuoglu O. & Basgul A. (2016) Pregnancy health problems and low birth weight associated with maternal insecure attachment style. Journal of Health Psychology 21(6), 934–943.

Saisto T., Toivanen R., Salmela-Aro K., et al. (2006) Therapeutic group psychoeducation and relaxation in treating fear of childbirth. Acta Obstetrica et Gynecologica 85, 1315–1319.

Scamell, M. (2014)Childbirth within the risk society. Sociology Compass 8(7): 917–928.

Scamell M. & Alaszewski A. (2012) Fateful moments and the categorisation of risk: Midwifery practice and the ever-narrowing window of normality during childbirth. Health, Risk & Society 14(2), 207–221.

Schwartz L., Toohil J., Creedy D.K., Gamble J. & Fenwick J. (2015) Factors associated with childbirth self-efficacy in Australian childbearing women. BMC Pregnancy and Childbirth 15, 29.

Spice, K., Jones, S.L., Hadjistavroulos, H.D., Kowalyk, K., & Stewart, S.H. (2009). Prenatal fear of childbirth and anxiety sensitivity. Journal of Psychosomatics and Gynecology, 30, 168-174.

Soderquist J.,Wijma B. & Wijma K. (2006) The longitudinal course of post traumatic  stress after childbirth. J Psychosom Obstet Gynecol 27, 113–119.

Storksen, H.T., Eberhard-Gran, M., Garthus-Niege, S., & Eskild, A. (2012). Fear of childbirth: The relation to anxiety and depression. Acta Obstetrica et Gynaecologica Scandinavica, 91, 237-242.

Sutcliffe K, Caird J, Kavanagh .J, et al. (2012) Comparing midwife-led and doctor-led maternity care: A systematic review of reviews. Journal of Advanced Nursing 68(11), 2376– 2386.

Ternström E., Hildingsson I., Haines H. & Rubertsson C. (2015) Higher prevalence of childbirth related fear in foreign born pregnant women – Findings from a community sample in Sweden. Midwifery 31(4) 445-450.

Topiwala A., Hothi G. & Ebmeier K.P. (2012) Identifying patients at risk of perinatal mood disorders. The Practitioner 256(1751), 15–18.

Toohill J., Creedy D.K, Gamble J. & Fenwick J. (2015) A cross-sectional study to determine utility of childbirth fear screening in maternity practice – An Australian perspective. Women’s Birth 28(4) 310-6.

Toohill, J., Fenwick, J., Gamble, J., Creedy, D.K., Buist, A., Turkstra, E., & Ryding, E.L. (2014). A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women. Birth, 41, 384-394.

Turris S.A. (2005) Unpacking the concept of patient satisfaction: a feminist analysis. Journal of Advanced Nursing 50, 293–298.

van Teijlingen E.R., Med M.A, Hundley V., Rennie A.M., Graham W. & Fitzmaurice A. (2003) Maternity satisfaction studies and their limitations: ‘‘What is, must still be best’’. Birth 30, 75–82.

Waldenstrom U., Hildingsson I. & Ryding EL. (2006) Antenatal fear of child- birth and its association with subsequent caesarean section and experience of childbirth. BJOG 113, 638–646.

Walsh D. (2007) Evidence-based Care for Normal Labour and Birth. A Guide for Midwives. Routledge, London.

World Health Organisation (2013). WHO recommendations on postnatal care of the mother and newborn. Geneva: WHO.

Wijma, K. (2009). Review of the phenomenon and occurrence of fear of childbirth (FOC) and its sequelae. A proposal for the study of FOC by Cognitive Behavioural Therapy. Unit of Medical Psychology, Department of Experimental and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.

Wijma, K., Wijma, B., & Zar, M. (1998). Psychometric aspects of the W-DEQ: A new questionnaire for the measurement of fear of childbirth. Journal of Psychosomatic Obstetrics and Gynecology, 19, 84-97.

Wiklund I., Edman G. & Andolf E. (2007) Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Acta Obstet Gynecol Scand 86, 451–456.

Wiklund I., Edman G., Ryding E.L. & Andolf E.(2008) Expectation and experiences of childbirth in primiparae with caesarean section. British Journal of Gynecological. 115, 324–331.

Williams K.J, Zolotor A. & Kaufmann L. (2009) Does group prenatal care improve pregnancy outcomes? The Journal of Family Practice 58(7), 384a–384c.

Appendix

Search Strategy – Cochrane library

CINAHL

	Search ID#	Search Terms	Search Options	Actions
	S5	S3 AND S4	Search modes – Boolean/Phrase	View Results (320) View Details Edit
	S4	S1 OR S2	Search modes – Boolean/Phrase	View Results (36,924) View Details Edit
	S3	(MH “Childbirth”)	Search modes – Boolean/Phrase	View Results (7,181) View Details Edit
	S2	(MH “Anxiety”)	Search modes – Boolean/Phrase	View Results (29,136) View Details Edit
	S1	(MH “Fear”)	Search modes – Boolean/Phrase	View Results (9,130) View Details Edit